Managed Health Care

One approach to cost containment is to manage the care that is provided to plan members.

Reference-based Pricing

Reference-based pricing (RBP) contains cost by limiting the reimbursement level of therapeutic classes. The costs of various drug therapies differ significantly. RBP establishes a specific cost per day as the reference and uses that amount to limit reimbursement for all drugs with the therapeutic effect of that class.

Managed Drug Plan

The most cost-effective drugs are reimbursed at higher levels than less cost-effective drugs. Real-time auditing of eligibility, appropriateness, interactions and compliance. Real-time adjudication to affect the purchase decision.

Dental Preferred Provider Organization (PPO) - Reimbursement

A defined benefit plan with a higher level of coverage if services are provided by a preferred provider. Discounts are negotiated and passed on to plan sponsors.

Dental PPO - Capitation

A defined benefit plan with preferred providers reimbursed fixed revenue per capita from the plan sponsor. Providers accept the financial risk. If fewer service are required than profit increases. Employees are limited in their choice of dentist.